Hospital Culture Importance And How Much More Likely Are You To Survive As Happy's Patient?

Aggravated DocSurg explains the importance of hospital culture as he dissects data from the ACS Surgery News

When you expect little, you get little in return.  I have full faith in the abilities of most folks at Happy's hospital that come in contact with patients in one way or another.  That which I am not trained to handle, I leave for others more educated than I.  As an internist trained hospitalist, the volume of disease I am capable of handling is immense.  My limits are well known to me.  And when they are met, I act accordingly.

Physicians also play an important role in following  protocols designed for patient safety.  If you have infection control policies in place that require full shield protection while placing central lines, the policies do no good if the physicians do not follow them.  If you have good policies in place to prevent venous thromboembolism (VTE), they do no good if the physicians are not active participants.   Physicians must be willing participants, along with everyone else, in a culture of excellence.

Some physicians don't seem to want to do the right thing for patient care.  Eventually, those physicians will be found out.  If they don't want to prevent  VTE in their patients, their numbers will eventually prove their failure.  If they don't want to barrier protect their patients from infection, their numbers will eventually prove their failure.

On a personal note, I am happy to report that my data is exceptional.  If you were taken care of by me, you were 50% less likely to die than your severity of illness adjusted expected mortality would have suggested.  Every year I get a report indicating my actual mortality % vs expected mortality %.   Some of this can be manipulated by how well I document, compared to the rest of the physician universe.  I understand the documentation rules very well.  That may, to some degree, skew my data when compared with the physician universe.  But so what.  It's accurate data.  And it's accurate when comparing me against my own data.  If my patient is sick, I document exactly how sick they are.

So how do my numbers look?  Well,  in 2008, 355 cases were evaluated.   The severity of illness adjusted expected mortality for my patients was 5.7%.   This compared with the national database numbers of 5.1%.  But how often did my patients die?  5%?  4%?  3%?  None of the above.

My patients died only 2.8% of the time.  Less than half my patients who were expected to die, did.   How did I compare with the rest of Happy's hospitalist group?  Despite having a higher severity of illness (which may be due to better documentation), I beat them out too with an actual mortality of 2.8% vs 4.5% for Happy's entire hospitalist group.  So not only are my patients dying 50% less often than would be expected, patients in my entire hospitalist group are dying 12% less often than would be expected when compared with national statistics.

Hospitals with strong safety initiatives and a culture of compliance with those initiatives from all players, including physicians, separate good hospitals from great ones.  And physicians that practice sound clinical medicine can expect more of their patients to survive their acute illness, despite all the barriers to their survival.  Quality will come from within, not from the government.  How many bad mothers do you know out there on welfare?  How many bad mothers do you know not on welfare?  What makes a good mother is the mother, not the government.

So what does it all mean?  If you should ever find yourself as a patient on my service, you can sleep well at night knowing that your chance of dying is 50% less than if the average physician in this country cared for you.  And should you ever find yourself admitted to Happy's hospitalist service , you can sleep well at night knowing that if you don't get me as your physician, at the least, you have a 12% less chance of dying during your stay than the average patient in the average hospital being taken care of by the average physician in this soon to be average country.

You can learn more about coding here in my coding lectures 

How Fast Can A Bear Run In Yellowstone Park?

How fast can a bear run in Yellowstone Park?  I was told by several bystanders, the bear can run up to 35 miles per hour.  A good reason why the laws in the Yellowstone  post 100 yards as the closest allowable distance to approach a bear.  On several occasions whole herds of wild humans would congregate on the side of the road to view the bears in action.    And everyone kept their distance.  At least 100 yards.  

Except this guy.

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Medical School vs Nursing School: Should We Shut Down All Medical Schools?

Nursing school vs Medical school. Should all medical schools just be shut down in favor of medical schools? Dr Rich gives his in depth analysis of the news behind the AMNews.

If students of nursing can pass the same competencies, in their entirety, as their MD  counter parts, they should receive the same rights as physicians to practice in equivalent scopes of practice.  Which means they should take the certification presented by the  American Board of Internal Medicine.  And if the ABIM is shown to be too difficult, physicians should certify by the standards established by their counterpart nursing boards.  

Having  two different certification standard to practice in the same scope of practice is simply irrational.

With equality defined in internal medicine, DNPs should also be allowed to pursue specialized training, should they desire, in new specialized tracks of training, called Doctor of Nursing Cardiology, Doctor of Nursing Gastroenterology, Doctor of Nursing Endocrinology, Doctor of Nursing Nephrology ( you get the point).  And once complete with their training, they should be allowed to sit for the certification exams presented by the American College of Cardiology, Gastroenterology, Endocrinology, Nephrology and on and on.  If these exams are shown to be too difficult for doctor nurses,  medical doctors of cardiology, gastroenterology, endocrinology and nephrology should be allowed to certify by the standards established by the doctor of nursing specialty societies in order to allow doctor nurses equality of standards.

Given the mantra of equal training,  and showing that nurse training is equivalent in scope and practice to the specialty of internal medicine, cardiology, gastroenterology, endocrinology and nephrology, nurses  should also be allowed to pursue a new doctor of surgical nursing degree.   Proving once again that if  higher nursing education requirements  are equivalent to medical education, they should be allowed to prove competency by sitting for board certification presented by the  American College of Surgeons, becoming equals with their MD surgical counterparts.

You see, there is nothing inherently different between the American College of Cardiology, the American College of Surgery and the American Board of Internal Medicine.  They are all certifiers of physicians in their field of expertise.   Each a speciality in their own right.   If nurses believe they can practice internal medicine in its entirety with their nursing degree, there is no reason for me to believe they don't also believe they can also practice cardiology and surgery, in its entirety with their nursing equivalent degree.  

Whether they choose to or not is irrelevant.  Should a nurse wish to pursue specialized training in cardiology or surgery and become certified as equals as their MD counter parts, I believe America owes it to patients and nurses alike to offer them this opportunity.

Which is why I favor closing all medical schools immediately and broadly expanding nursing admissions to provide for the new wave of doctor nurses who can provide full scopes of internal medicine, cardiology, gastroenterology, endocrinology, nephrology and surgery.  To deny doctor nurses the opportunity to certify as equals in all these fields would be denying patients and doctor nurses alike the rights earned by nature of their training to practice in scopes determined to be equal as their MD counterparts.

If the educational outcome is the same, then as a country, we should be paying for the cheaper education.  That means it's time to shut down all medical schools for good and use the nursing model of care as the only model of care to evaluate and manage patient illness.

How Does A 98 Year Old Present To The ED?

I snapped this picture in a public ED.

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It's Illegal To Discriminate Against Whites (Says the Supreme Court)

Why did it take the Supreme Court to decide discrimination against whites was illegal (link no longer available)?

Punishing whites because minorities failed to meet the standards of the job is a form of racism.  We can argue till the cows come how about the disparities in minority opportunity.  But it doesn't change the fact that standards are in place for a reason.  Is it acceptable to lower the standards for a defined  job for the sole purpose of increasing minority participation?  By doing so, you are making the presumption that minorities are by default less capable.  That in itself is a racist idea and lowers the standards for all to participate.  This mentality is a race to the bottom.

Let's take medical school for example.  If the minimum requirement at Harvard  was a 30 on your MCAT and a 3.5 GPA, would you keep out a white student with a 4.0 GPA and a 35 on their MCAT because not enough blacks meet the standard admission criteria?  Of course not.  If there cannot be equal standards for all, there should not be any standards at all. Setting different standards based on race is in itself racism.  Punishing one race for their success because another race failed to meet the required standards is racism.  

And the Supreme Court got it right.  It's just too bad it took the High Court to see that.

Italian Greyhound Looks At Buffalo In Yellowstone Park (Picture)

Here's Cooper, our Italian greyhound, looking at Buffalo in Yellowstone. I'm not sure what he's thinking.

Emergency Physician Lawsuit Immunity? What Do You Think?

Should emergency room physicians be given immunity from lawsuits?  Chris Seper over at Medcity News discusses effort underway in his own backyard to do just that.

The Ohio bill would specifically apply to services being provided under EMTALA regulations. I would interpret that to mean any physician taking care of a patient that was seen or admitted to the hospital through the emergency room would be protected by this higher standard.  That includes hospitalists and all other subspecialists that care for hospitalized patients admitted through the emergency room.  I can't recommend hospital admission on an ED patient and then sign off.  By default, that makes me fall under the same rules as an ED doc.

The only problem I see in today's malpractice environment is the irrational standard of care that has been established, not by science, but rather by the fear of the lawsuit itself.  Everyday of my life I see head CTs ordered on patients with drug overdoses because they are acting funny.  Should that be the standard of care?  Of course not.  Is it?  Yes.  Because just one of those patients may have fallen or bumped their head and experienced a subdural hematoma.  In the six years I've been practicing as a hospitalist, most of my patients who  have been admitted to my service with altered mental status and a drug overdose have had a CT scan.  A normal CT scan.  Now, I fear the doctor who doesn't order one on that one patient who has a bleed AND a drug overdose.  They're toast.  And because they're toast, everyone gets a CT scan.  That's the standard.   But it shouldn't be.  And it's a legally driven mentality that feeds on itself.  All us docs know the likelihood of having a drug overdose AND a head bleed as the cause of the altered mental status is minuscule.  But none of us are willing to be the doc who doesn't order it just that once and be wrong.

When the standard of care in a community is the wrong standard;  when it's based on fear rather than science, everyone loses, except the lawyers.  It's time to discard standard of care as the legal basis for malpractice in this country.  And find something that isn't bankrupting our country.  What's the answer?  You tell me.

Other Alternative Income or Revenue Sources For Primary Care Doctors

Dr Brayer describes how to survive primary care with other alternative income or revenue sources.   That's really sad that being a primary care doctor has come to this.  

One Handed CPR? Weird.

One handed CPR? Strange indeed.  I've done CPR on some pretty frail elderly.  I can't say I've ever seen it done one handed.

Gawande's Research Reanalysis

McAllen, Texas is the mother ship for the Medicare National Bank. A culture of care that is bankrupting our country. Or so we think. A reanalysis of Gawande's research was done by the ladies and gents over at the Health Care Blog  analyzed the data. And came to a very different conclusion.

They did some great analysis of the data to come to these conclusions. They showed that the expenditures out of McAllen in patients without diabetes, heart disease or heart failure was not out of the ordinary.

My own analysis? Before I could conclude that an over treat culture of care in McAllen doesn't exist, I would like to see the data, not on patients without these three diseases, but rather expenditure data on patients WITH diabetes, heart failure and heart disease and corrected for poor status (who's poor health is directly related to smoking status). These are the patients for which medical care is expensive. These are the proceduralized patients. Telling me that healthy folks in McAllen cost no more than healthy folks in Colorado doesn't mean anything. Tell me a rich diabetic with heart failure and a history of MI costs more in McAllen than in Colorado. Now, that's meaningful information.

Optogenetics: Bizarre Brain Research

I reader pointed me to some crazy brain research. Optogenetics.  That's some bizarre brain research going on.

I wonder how many RVU's that would pay?

What Is It Like To Be A Nurse?

What is it like to be a nurse?A nurse tells it like it is

And no one is just a nurse. For all the nurses out there, I respect the nursing work you do. It's one of the toughest jobs in health care. I for one could never do it.

Paid Drug Company Lectures

Have you ever been given the opportunity to give a paid drug company lecture?  I was given the opportunity to lecture on Invanz. I was told I would be given the slides to do the lecture AND it would only take about 15 minutes.  And I would be paid $1,000 for my time. 

It's not OK to give a doctor a pen, but it is OK to pay them a $1000 in consultation fees. I find this whole thing preposterous.  I turned them down due to my busy schedule. The question is, would you?

Caption Contest

Lawyer Patients Treated Differently?

If a patient tells you they are a lawyer, how does that affect your evaluation process?  Do you treat lawyer patients differently?  Be honest.

Goat Rodeo Known As American Health Care

The goat rodeo known as American health care:
 

According to Panda Bear the four most expensive words in all of American health care are "Just to be safe".

I have used that line frequently.  And each time I do, I internally rationalize whether the tests I am recommending will ultimately affect my management decisions for my patients and whether those decisions have the ability to change the outcomes of my patient.  If we physicians cannot defend our medical decisions based on sound scientific principles, in the correct clinical scenario, we are part of the problem.    

The more we screw America, the more we screw ourselves.  If we are going to stick an endoscope in a 92 year old,  we are part of the problem.  

Buffalo On The Road In Yellowstone During Spring (Picture)

Here is a picture of buffalo on the road in Yellowstone during Spring. A mama and her calf walk down the road.  A beautiful sight to see. 

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What Doctors Really Mean When They Speak: Doctish English Phrase Book

What doctors really mean when they open their mouths and speak: Dr Hal Dal brings us an up to date explanation of doctish English

My favorite You will experience some discomfort. (really means) This will hurt a lot.

Who/What Is Responsible For Rising Health Care Costs? America Responds

Who or what is responsible for rising health care costs?  America responds.  From the Economist.com

Fascinating. Insurance companies (like every third party) isn't without its problems. But, exactly how are insurance companies to blame? When you wreck your Ford focus and it costs $1000 to repair the bumper, is that the fault of State Farm? Insurance companies collect money from you, take a small cut, and then pay for your neighbor with the 30 medical problems to sit on her couch smoke cigarettes, eat Cheetos and watch Oprah.

The public has no idea how inefficient our health care is because of the massive government regulatory structures in place that demand inefficiency. A self fulfilling spiral of financial doom that feeds on itself and guarantees millions of Americans jobs for no other purpose than to support the bloated structure known as American health care.

The public's perception and the reality of the situation are in need of a major educational initiative.

What Killed Michael Jackson?

What killed Michael Jackson? 

The news says it was a heart attack.  I'm not so sure.  There are so many variables here, it's hard to know where to begin.  First of all, in medical jargon, physicians often think of a heart attack as a myocardial infarction, a condition where a sudden occlusion of a major arterial vessel to the heart results in a loss of oxygen to valuable heart muscle.  There is a whole spectrum of ischemic disease.  It can start with stable angina, a relatively benign condition that can be managed for years with appropriate medications and elective procedures.  More concerning is unstable angina, or chest pain or its anginal equivalent that generally occurs at rest.  Most physicians would consider unstable angina a reason for  hospital admission and close hospital monitoring.

Progressing farther along the cardiac spectrum, non ST elevation MI occurs when lack of oxygen to the heart results in damage to heart muscle that results in leakage of cardiac specific enzymes into the blood stream.  It is this cardiac marker, the troponin, that physicians use to measure the presence or absence of cardiac muscle death.  The lack of ST segment elevation generally means that the damage is not transmural.  In other words, the full thickness of the heart is not being compromised.  This can is also generally managed in the hospital as a non life threatening condition.  And depending on the clinical scenario treatment can include medications, PCI, surgery or a combination of the three.

The ST segment elevation MI is the emergency that kills.  How quickly you intervene has everything to do with life or death.  ST segment is an ECG finding that indicates  trans mural, or complete thickness death of the cardiac muscle.  With out specialized interventions, either tPA or PCI, the patient will have a high probability of severe morbidity or death.

So, did Michael Jackson have a "heart attack", classically understood by physicians as a myocardial infarction (MI)?  I don't know.  The most important risk factors for acute MI are:

• diabetes
• hypertension
• hyperlipidemia
• smoking
• central obesity/inactivity
• family history
• history of vascular disease in other sources

Other less common but still relevant causes include

• systemic inflammatory disease such as autoimmune conditions (lupus, rheumatoid arthritis)
• illicit drugs (meth, cocaine)
• coagulopathy (perhaps antiphospholipid antibody syndrome)
• radiation exposure
• untreated hyper or hypothyroidism
• Prinzmetal's angina

There are many others but these are most common.

Mr Jackson, on the surface doesn't appear to have major risk factors for premature coronary artery disease that could lead to an early MI.  I've never seen him smoke.  His family all appears free of heart disease.  He is physically active.  He probably does not have diabetes, nor hypertension.  His cholesterol status is unknown.  He very well may have an autoimmune disorder as he has claimed to have many ailments over the years.  However, having systemic lupus would make it quite difficult for him to lead an active lifestyle as he has.

While possible, I'm not convinced it was an MI per say that killed him.  I think the more likely cause may have been sudden cardiac death, not by infarction  of one or more blood vessels , but rather by a global hypoxemia caused by a deadly arrhythmia, most notably ventricular tachycardia or ventricular fibrillation.  Now, either rhythm can be initiated by a myocardial infarction, or they can be a primary source of death.

Someone with intrinsic coronary artery disease is more likely to have VT or VF than someone without, but VT and VF can occur in those with out active ischemia or infarction.  QT prolongation or other genetic arrythmogenic conditions could have caused his demise.  Hypertrophic obstructive cardiomyopathy could have as well.    Street drugs, herbs,  supplements and prescription drugs could all initiate a deadly arrhythmia.

The autopsy will be helpful to determine the extent of coronary artery disease, if any.  If he appears clear of underlying chronic disease, one would have to start looking towards more acute causes.   Drug overdose. Primary respiratory failure.  Pulmonary embolism (he does travel quite a bit).  The information on the field will be helpful ( in terms of what the cardiac rhythms were), what he was doing when he collapsed, any discussion with folks around him right before he collapsed.  It can all be pieced together to get a final cause as the most likely cause of death.

Because, as all physicians know, cardiopulmonary arrest is not an appropriate cause of death.

Biggest Tomato Plant Ever. It's Like a Freakin' Tree (Picture)

Is this the biggest tomato plant ever?  It has to be close. It looks like a tomato tree.   From sister Happy's garden comes the biggest tomato plant I have ever seen and they don't even have raised garden beds to help them out.  See the tomato plant picture below.  

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Canadian Medicine Truths.

Here is the truth about Canadian medicine.

 You may think all is well in Canada. A land where FREE=MORE has been granted a birth right. It has been said many times before: You have three endpoints for which to strive for. Cheap, Quality or Quick. Pick any two. You can not have all three. It seems that Canada has decided to sacrifice Quick. You can always guarantee cheap health care. You simply stop paying for it. That's called rationing. Getting in line and waiting is a classic form of rationing used by governments all across this land of ours.

In fact, as a resident in training at a VA facility, I saw first hand how rationing of care occurred using waiting as the tool of choice. Schedules blocked at 5-8 patients. Leaving when the clock struck 4. Scheduling dead patients. Yes folks, that actually happened. As an inpatient, technologists would finish their day on their terms. Getting studies after hours was impossible. Patients would wait for days to get an echo or a doppler. I once had an xray technologist refuse to come in, from home, in the middle of the night to take a chest xray on a crashing ventilator patient. The fact that the VA would not staff an overnight xray technologist was simply ridiculous. Try to get anything done on a holiday. Not only impossible but the hoops one had to travel through to attempt it would make Obama cry if he had any idea what the government run care was doing to his Vets.

Wait times is rationing, no matter how you look at it. You can find the link to the Fraser Institute on Canada's Wait times here at Dr Hal Dall's blog. I want to thank him for pointing it out. It is a fascinating look into the discrepancies in Canada's health care, in spite of the equality for all mantra of social solidarity.

Favorite Patient Ever. (Amazing!)

Check out my most favorite patient ever.  Amazing.  

Patient Requested Procedures: I Want A Bone Marrow Biopsy Tops Them All.

What are your thoughts about patient requested procedures.  How about a patient requested bone marrow biopsy?  I recently wrote how it is OK to do nothing when asked to evaluate a patient as a subspecialist. An oncologist responded with this unbelievable comment.

I am an oncologist. Recently, I had a patient sent to me for a mild lab abnormality. Two years ago, she had been seen by another oncologist, and told that it was a benign process. Now, with two additional years worth of labs showing absolutely no change, I concurred with the initial evaluation and told her no additional testing was needed. The patient told me "my PCP told me that he will feel better, I will feel better, and you will feel better if you do a bone marrow biopsy to make certain." I don't feel better doing better marrow biopsies....especially when they are for very weak indications. It is that unveiled threat of failure to diagnosis that drives so much inappropriate testing. I discussed the case with the PCP. We agreed that a bone marrow biopsy was not indicated (and he had never made the above statement to the patient). Unfortunately, in our now-is-when-I-want-it-done society, watchful waiting doesn't go over well (plus or minus that "irrational fear" of legal liability).

I can't think of any rational reason why a patient would want to subject themselves to a bone marrow biopsy after two oncologists suggested, in their expert medical opinion, that one was unnecessary. This procedure is not without pain. In fact, it can carry a significant amount of discomfort. It is not cheap. It carries with it highly specialized pathological processing and interpretation. Why would a patient subject themselves to such an ordeal? May I suggest that they wouldn't, if they had to pay for it, even a portion of it. FREE=MORE

I might add that from a legal standpoint, physicians establish the standard of care. If everyone with a mild abnormality gets a bone marrow biopsy because physicians say they should then not doing one would establish a practice outside the standard of care. However, I have a problem with using standard of care as the basis for making determinations of negligence.

Just because it is common practice to do bone marrow biopsies on everyone with an abnormal lab, does not make it appropriate care. Take for example McAllen, Texas, a place that appears to have a culture of excess when it comes to testing and intervention. Is that standard the right standard? Would not doing a bone marrow on everyone with a lab abnormality open one up to negligence because everyone else is doing them? It does, but it shouldn't.

If the standard of care in a community is just wrong, how can one defend oneself against allegations of negligence when they went against the grain of what other physicians in the community would do?

I don't have a good answer for that. Guidelines have been heavily infiltrated by specialty societies. Many aspects of guidelines carry suspect recommendations based on suspect financial motivations. So much of medicine is based on medical judgment. There simply aren't guidelines. Many guidelines are based on a nice pretty package of healthy white men between the ages of 19 and 65. Many guidelines cannot be extrapolated across diverse populations. Many guidelines differ widely between different specialty societies and other nonprofit organizations.

So where does that leave the physician? They are stuck. Damned if you do and damned if you don't. If every doc in town is doing bone marrows on patients with slight abnormalities, you can be assured a lawyer will come knocking on your door if you don't do one on a patient you don't think needs one AND a delayed diagnosis is ultimately made.

By falling into that trap, you doctor are establishing an irrational standard that can never be achieved. A standard that is bankrupting our country out of a fear of preventing a bad outcome. When in fact, by doing more, we are actually causing more harm than good. Every study you find shows poorer outcomes in areas with a higher percentage of subspecialists and lower percentage of primary medical doctors.

It's time physicians take back their profession and establish standards based on sound scientific principles, personalized for every patient based on their extensive medical training, and stop making medical decisions based on a fear of deviating from irrational standards of care which they themselves create. The only folks getting rich off the brilliant legal scam known as standard of care are the lawyers filing claims and the unscrupulous doctors doing highly lucrative procedures (as determined by RVU/RUC) under the guise of standard of care. While patients are getting harmed and the Medicare National Bank is going bankrupt.

Would You Work a Month For Free (Request By British Airways)

British Airlines asked it's employees to work a month for free:

one and four weeks

How is working for free any different than being unemployed?  Either way, you aren't getting a paycheck. Perhaps one could rationalize keeping their job.  But there is no guarantee that that would happen any way.  

In health care, depending on your payer source, many docs see 10%, 20%, 30% or more of their patients for free.  It certainly isn't 100%, but with declining payment and increasing costs, some physicians find themselves heading right into bankruptcy.  It's not unusual to find your practice go up in smoke if the business model finds its way into a heavy Medicare and Medicaid population.  Some physicians I have spoken with are forced, by their business managers to cap the number of Medicare and Medicaid patients after their quota is met.   It's the only way to survive in the socialistic payment model and capitalistic expense structure that has become American medicine.  Your office is a business first.  If you aren't open for business, you aren't practicing medicine.

Working for free is nice, when you do it on your terms.  It's called volunteer work.  Being forced to work for free is called slavery.

Why Can't I Stick A Cotton Swab In My Ears, But I Can In My Nose?

Why can you stick a cotton swab in your nose but you shouldn't stick a cotton swab in your ear?  Another pressing question for the day asked by a reader.

My question is a two-part question. 

Part A: Why is it wrong to stick a cotton swab in your ear but perfectly OK to stick one up your nose?

Part B: Do doctors ever use cotton swabs to clean their own ears? If not, how do you get the water and stuff out of your ears after a shower?

You shouldn't stick cotton swabs in your ears because you can injur your tympanic membrane.   With that said, I personally have never seen it and have no idea how common that is.  As for the cotton swab up the nose, I can't say I've ever heard of anyone doing this.  But I can't think of any injury that may occur.  There aren't any membranes in your nostrils that a cotton swab could damage (that I know of).

With that said, I do use cotton swabs to clean my own ears.  I guess you could call me non compliant.  But I can't say I ever have a problem with water in my ears.  Perhaps my ear hairs have formed a nice barrier.   Mrs Happy keeps them nicely trimmed.

Should I Change My Own Blood Pressure Medicine Dosing?

Hypotension causes:  A reader wants to know if it's OK to change their own blood pressure medicine dosing:

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Doing Nothing Is Still An Option In Medicine

Doing nothing is still an option in medicine. 

Over at KevinMD a post suggested that outpatient primary medical doctors should have their fees raised by reducing the fees of subspecialist. Under current RVU/RUC rules the physician payment system is a WIN/LOSE system. For every winner there is a loser.

Years ago as a resident, we had a patient we were consulted on for a deep venous thrombosis from another service.   For whatever reason, another service was consulted as well. I ran into that team.   I explained that the patient probably got their VTE from a surgery they had several weeks prior. I asked them if they were going to order the horridly expensive profile of coagulopathy tests. And you know what they said to me?

We usually would not, but since we were consulted we probably would.

After discussing the case we decided not to order all the tests that cost thousands of dollars to run. I bring this up in relation to the above comment because of the above specialist's comment.

Just because you consult as a specialist, doesn't mean you HAVE to do something. As a hospitalist, a lot of what I do is watchful waiting. I don't do anything and the patient gets better. Just because a primary MD sends a patient to you as an orthopaedist doesn't mean they have to do anything. If the question is what to do, doing nothing is certainly an option.

I think this is an important difference between primary trained MDs and subspecialty trained MDs. Being a subspecialist does not relinquish their right for watchful waiting. But I find many times that concept is alien. Perhaps it's the thought that not doing anything will not please the primary. Perhaps not doing anything means a loss of procedural revenue. Perhaps not doing anything leaves open an irrational fear of legal liability.

Whatever the reason,I don't believe subspecialist  suggests that primary MDs refer patients because something has to be done. Sometimes, it just doesn't. Really. Doing nothing is still an option.

How Many Blogs Do You Follow?

With vacation, summer weather, busy work, and Mrs Happy's unexplained desire to spend time with me I haven't been able to follow my favorites for almost a month. At some point I will tune in. With that said, I have 350 blogs in my cue. There is so much great stuff out there.

How many blogs do you follow?

Hospital Transcription Department At Happy's Hospital Gets Kudos

The hospital transcription department at Happy's hospital gets kudos from me.
 

As many critics of hospitalist medicine know, for every hand off a voltage drop of information can occur. I personally make every effort I can to thoroughly review the chart when I come on to a new service for the week. I also try and leave detailed explanations about the status of my evaluations when I go off service.
But what about the discharge? Since Hospitalists generally don't follow their patients once they leave the hospital, there is a high probability of bad things happening between the time of discharge and the first appointment with the patient's outpatient internist or family medicine doctor. This no man's land can possibly lead to readmissions as neither patient nor hospitalist nor primary MD have any idea what's going on.

One way to reduce this voltage drop of information is to have systems in place that make sure the patient's primary MD gets the hospital discharge summary in a timely manner. So how do I define timely? My definition is 24 hours. I learned yesterday that 81.9% of hospitalist discharge summaries are transcribed in 0-12 hours. 14.8% are transcribed in 12-24 hours. That means almost 97% of all Happy's hospitalist discharge summaries are automatically sent to the patients primary MD (and any other subspecialist noted) in 24 hours or less.

Since we have a policy in our group of doing discharge summaries immediately upon discharge, patient information is received by the primary MD in almost all patients within 24 hours. I can't say the same for many subspecialty services where we are asked to readmit several weeks after their primary discharge, in which there is no discharge summary to be found.

Because I find many subspecialty groups do not dictate discharge summaries in a timely manner, I will dictate a letter to the primary MD on many patients I am consulted on. Why? Because I know that no discharge summary will be performed for a month or more. And I feel bad for the primary MD and patient for bouncing from doctor to doctor with no easily accessible written record (and especially no verbal communication either).

We live in a fragmented system of health care bouncing between hospitals and clinics with no easy way to hunt down information. I dictate these letters (which by the way are completely voluntary and uncompensated by anyone) out of a personally duty to limit the loss of information as patients bounce around in no man's land.

Happy's hospital group has also surveyed our referring primary MDs to learn how they like to be notified (phone call or not) upon discharge. We will call if they want. We won't if they don't. But they will always (97% of the time) get our discharge summary in 24 hours or less.

That's how you provide great quality care. And I can assure you, as bundled payments come our way, hospitals will intensify efforts to improve their in house processes to limit readmissions. Decreasing volatge drop is one such effort that will be taken. They will do this because they have to. Just like every hospital in this country hired chart police to scour physician documentation to maximize payment as determined by the Medicare National Bank.

So congrats Happy's hospital transcription department on a job well done. You are an example of how things should be done.

Obama Is Still Smoking And the Hypocrisy Continues

Obama is still smoking. Unfreaking believable.  The ultimate act of hypocrisy continues.   You can't talk about health care while blowing smoke rings.   You might as well be blowing smoke out of your ass.   You have no credibility as a health care advocate when you mock healthy lifestyles. 

Like a tell all my smokers who say they've "cut back".  There is no such thing as being kind of pregnant.  You are a smoker or you aren't.

Update.  Obama may have quit smoking for good.  Why did Obama quit smoking?  

Liquid Viagra Announced. Will Be Marketed by Pepsi As A Mixer. (Joke)

Pfizer Corp. announced today that Viagra will soon be available in liquid form, and will be marketed by Pepsi Cola as a power beverage suitable for use as a mixer. 

It will now be possible for a man to literally pour himself a stiff one.  Obviously we can no longer call this a soft drink, and it gives new meaning to the names of 'cocktails', 'highballs' and just a good old-fashioned 'stiff drink'.  Pepsi will market the new concoction by the name of: MOUNT & DO.

Thought for the day: There is more money being spent on breast implants and Viagra today than on Alzheimer's research.  This means that by 2040, there should be a large elderly population with perky boobs and huge erections and absolutely no recollection of what to do with them.

How Much Does A Hip Replacement For A Dog Cost?

How much does a hip replacement for a dog cost?  You would be surprised. Dr Khuly at the blog Dolittler explains
 

Now I ask you Obama and company. How is it that equivalent procedures in almost every way costs 1/10 for a dog than it does for a human? Would we intentionally implant infected hardware in our little Marty? Would we intentionally operate in unsterilized suites on baby Cooper? Would we intentionally provide bad veterinary care to all our best friends?

Of course not.

So how can we offer bilateral hip replacement for 1/10 the cost? I can answer that. 10% of the cost is good medical care. The other 90% is drowning in a regulatory frame work that adds nothing of value to patient care. The only folks getting rich off of government care are the lawyers and public officials who guarantee themselves job security with every new hurdle introduced. As we drown in a sea of regulatory hurdles, we have out priced just about every family's ability to afford health care. We should be looking to different models of care that allow for good quality care at an affordable price. Imagine how many lives could be saved if American health care cost 1/10. Imagine how much more competitive America would be if our country wasn't' trillions in debt in unfunded Medicare entitlements. Imagine how much more competitive America would be if companies weren't straddled with $10,000 a year premiums.

America. You should be ashamed of yourself. The problem isn't bad health care. It's bad government. Only when you get the lawyers out of the equation will you get top quality care for 1/10 the price.

Addendum: My Egyptian Uncle had an uncomplicated heart bypass surgery in an Egyptian hospital by highly competent Egyptian doctors last year. Total cost for everything? $9,000. The issue is the cost structure underlying the delivery of medicine. It is not bad quality or bad medicine. It is bad government.

Why Did My Tomato Plants Die? (Pictures)

Why did my tomato plant die? 

I'm wondering if all the other plants got together and sacrificed this little buddy to save themselves. Everything is doing great, except this one lone tomato plant. It's kind of sad in a way. I don't have any idea why.

An Internist Offers Far More Than Primary Care

An internist offers far more than primary care.  A reader over at A Nurse Practitioner's View responded to a post by author Stephan Ferrara, NP. A post which does not represent my views at all. In response to Stephan, a reader leaves the following comment

Jane Know said...

Wow, how condescending is he? Yet, I do agree with the Happy Hospitalist that a medical education is superior to nurse practitioner programs. I don't know who would dispute that. But he's forgetting that most NPs have been in the real world practicing as nurses for several years, too. That real world experience counts for something that you can't learn in a medical textbook in school. Further, NP programs have pretty rigorous academic standards themselves, these days. Anyway, once we are all out there practicing as MDs and NPs in primary care settings, we are on pretty even playing fields. I know incompetent doctors and superior NPs. That is not a generalization about either profession, just a statement that sometimes the best education is on-the-job, and also variable depending on the individual. To me, it seems like the Happy Hospitalists may be focusing a bit too much on the status of MDs, and not as much on solving real world problems like primary care provider shortages and health care costs for people who can't afford doctors.

June 18, 2009 5:54 PM

I would have to respectfully disagree with most of these assertions.

1. Being a nurse for 50 years will not prepare you to practice a full scope of medical practice. The nursing career and responsibilities are simply not the same. I could be a doctor for 50 years and have no ability to practice nursing independently, even though I am around nurses in their capacity all day long. The two career pathways are not interchangeable. Nursing education and nursing experience does not prepare one to meet the requirements to practice independently in the same scope as an MD. If that was the case, we should all abandon medical school in favor of nursing school and nursing experience.
   
2. NP programs have rigorous standards. That's great to know. Now I ask you to put those standards up against any medical school and you will find that the two simply don't compare. It's not even close. In fact, if you knew how less rigorous your training was compared to any MD degree, you would be frightened at how under educated you would be to provide a full scope of care equivalent to your MD trained counterparts. Perhaps you feel MD training over qualifies one for the role you see yourself providing in the primary care world, independently. I might suggest you have a vastly inferior scope of practice in mind, or perhaps you don't understand what it means to practice independently. I can assure you with 100% certainty, that your rigorous training would not provide you with the skills to practice independently in the same scope as MD trained physicians. I'm sorry to break the news to you.
   
3. I'm sorry to burst your bubble once again, but in the real world primary care setting, you are not on even playing fields. The reason you feel this way is because you simply don't understand what being a primary care physician means. And you believe, foolishly, that your NP training provides with the skills to practice independently on par with the MD trained. I'm here to tell you, categorically, you may be able to practice primary care, as defined by you, but you cannot practice in the the same depth of scope as an MD trained internist. As an internist, I am trained to take care of many organ specific conditions independently. I do not call myself a cardiologist or a pulmonologist or a nephrologist because I am not trained to practice a full scope of those specialties independently. As such, you can provide primary care as defined by you, but your ability to provide an equal scope of services is limited as well. Your view of primary care is simply myopic. You will only understand what you experience. And your experience as an NP will be vastly inferior than an MD trained internist. That's not insulting. It's reality. You just aren't trained to do what I do.
   
4. Sometimes the best education is on the job. I am going to have to disagree with on that as well. I certainly would not want you practicing on me as a full scope independent practicing NP when I come to you expecting you to be an expert in your field. As a resident, I had multiple levels of supervision. There were always experts looking over my shoulder, correcting my mistakes and guiding me towards the right answers. I would never subject myself to caring for someone while learning "on the job." If you want to learn on the job, you should go to medical school and get a residency and have a team of experts watch your back.
   
5. Substituting a NP for an internist because there are too few internists is like substituting an eagle scout for a para military special forces agent because all the agents have quit or retired. NP and MD training are not interchangeable. An eagle scout can do a lot, but most can't kill with their bare hands. In the same regards, NPs may be able to do a lot of what MDs do (including specialists), but they also can't do a lot of what most MDs do. I don't understand where in the course of training, folks decided that NPs could practice independently in primary care but not subspecialty care. There is nothing special about being a subspecialist, except the extra several years of training. I would suggest that NPs take a 500 hour clinical experience, do ten heart caths, ten TEEs and become certified as independently praciticing cardiology NPs. The suggestion that these NP cardiologists were "on even playing field" with their MD cardiologists would be laughed out of town by just about every health care entity in this country. I view with hilarity the same assertion that NPs and internists are on even playing fields. The several years that differentiates my practice of cardiology from a cardiologists practice of cardiology is the how I think about NP vs internist training. In fact the difference is much greater do to the lack of medical school level education. I would never claim to be a fully independent practicing cardiologist because I am not qualified to do so. As such, the insinuation that an NP can practice outpatient internal medicine independently is absurd. And any NP who believes they are "on even playing fields" is ignorant of their own ignorance. You are the type of practicing provider I fear the most. Just as I would fear myself if I claimed to be an independently practicing cardiologist. This is reality. Your scope is simply not anywhere near the depth of scope a physician is capable of. You can define your scope as you wish. But understand, your lack of training does not provide you with the same capabilities as an internist. But your claims of being "on equal playing fields" is intellectually dishonest. You have medical skills. You also have nursing skills. You don't have internal medicine skills. Sorry to be the one to tell you. And internal medicine skills are required to practice a full range of outpatient primary care.
6. I have no illusions about the "status" of MDs as you call them. I find myself no more special than the cable guy. I am trained to do what I do because I invested the time and energy, determination, hard work, sacrifice and delayed gratification to excel in the practice of internal medicine.. I would expect nothing less from my physician caring for me in my time of need. You believe I think physicians are better. I don't. I think they are much better trained. As they are. By exponential amounts on the basis of their education and experience as medical students, residents and practicing doctors. That doesn't make me better than you. It makes me more educated than you. And that makes my scope vastly superior to practice internal medicine than those who haven't experience the rigorous training. I respect everyone for their contributions to this world we live in. But to believe you are on an "even playing field" is a clear indication of your lack of insight into what primary care is and what you believe it should be. I ask you go read Dr Centor's blog as indicated below.
   

Dr Centor over at DB's Medical Rants does a great job summarizing what I believe to be the semantics of this discussion. Primary care is misunderstood. It's misunderstood because those not trained to provide it don't understand what the scope entails. Many folks believe it means primary prevention. Dr Centor discusses below the difference between primary, secondary and tertiary prevention.

Yet, we know that high quality primary care does save money. I believe Verghese is making the classic mistake of defining prevention only as primary prevention. Those who study epidemiology and health services research understand that the real value occurs in secondary and tertiary prevention.

Time for some prevention definitions:

1. Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
2. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptom.
3. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications

As most medical students, residents and fellows can attest too, the vast majority of our training is spent managing complications of disease, not the disease itself. It is impossible to appreciate how to manage a disease, without seeing the thousands of permutations of complications that present themselves. It is difficult, to nearly impossible, to be an excellent provider of medical care if you don't know how to manage the complications. It is difficult to understand how to proceed with secondary and tertiary management of disease without first becoming an expert on the complications of those disease.

This is where the magic of residency and fellowship happens. As physicians, we are experts in complication management. Primary care is not primary prevention. Primary care is primary + secondary+tertiary prevention. And it is complication managment when those efforts fail. It is with MD level training that one begins to appreciate the subtle nuances required to understand the physiology and pathophysiology in patients with chronic medical disease. How multiple medications interact. Their side effect profiles. Their complications and exacerbations. This is not primary prevention. This is primary care. This is internal medicine. It is a rigorous process where we learn to differentiate patients from guidelines and make medical judgments on an individualized basis. You can't learn a full scope of this in NP school. You can't learn this after 50 years of nursing. You learn it by studying the full skill set necessary to achieve that end.

So Jane and Stephan, I respect you. I respect you for your skills. I respect you for your education and desire to advance your patient management skills. You have me all wrong if you believe I believe you have no value in patient care. You do. And you have an important role in patient care. But you can't do what I do, no matter how many years of on the job training you experience. I will not back down on my assertion that independently practicing NPs should be held to the same standards as all other independently practicing MDs. You may practice primary care, but you don't practice family medicine. And you don't practice internal medicine. You practice primary care, some vague unknown entity that you have defined by your own skill set.

Perhaps the fact that most of the public has no idea how to differentiate internists from family medicine MDs from NPs works in your favor. Perhaps you have gained legislative equality in many districts at the expense of educational equality. That's something that will eventually play itself out. I do know, based on my own training and experiences that should I ever find myself in a condition that requires the skills of an internist, an internist is where I am going. An internist who has far more to offer than primary care.

MRSA From Your Pet? Really?

Did your pet give you MRSA or some other infection?  The Lancet is reporting fido may be your vector for MRSA. One more reason to sterilize your pets.  I wonder what effect that will have with a pet therapy dog in the hospital.

World's Greatest /Best Beer Mug Ever. It's Got A Beer Ringer! (Pictures)

Here's a picture of the world's greatest or best beer mug ever. Now that's funny. Just ring for another beer.

Drug Company Agreement and Medicare Part D

The drug makers have agreed to cover part of the costs of brand name drugs in the donut hole, that no man's land of Medicare Part D where patients must pay for their own drugs.

I see one problem with the assertion that drug companies will be "spending" $80 billion dollars to reduce the cost of drugs for seniors. Drug companies and by default, their board of directors have allegiance to their shareholders, not the the US government or the seniors of this country. I can assure you, this deal may look good on paper (for seniors) and it may benefit seniors a great deal (FREE=MORE) but it is also one step further to the promised land of the senior vote. And it will worsen access to drugs for everyone else. There is no free lunch in this world.

It may save seniors money, but it will not be revenue neutral. It will not save $80 billion dollars over 10 years or reduce overall costs of care. Somehow, someway, the costs will be shifted. It may mean higher drug costs for those privately insured or the uninsured. It may mean decreased access to compassion programs. It may mean higher costs to hospitals. Whatever the agreement means, it will not mean $80 billion dollars saved in the next decade.

Drug companies are not in the business of sacrificing their shareholders or bond holders for patriotic means. They are in the business of making money. And that means they have selfish interests to maximize their ROI for any agreement they make with the government.

The question isn't really how wonderful this is for seniors. The question is how will buying off seniors affect the rest of America. And I'm telling you here, right now, you will see higher costs for everyone not lucky enough to bath in a sea of FREE=MORE known as the Medicare National Bank.

Mount Rushmore Head Picture

Just another Mount Rushmore head picture. I don't think anyone has ever done that before.

Any objections?

You Are Living In The Medicare Tomato

In case you missed it, The Medicare Tomato, a post I wrote last year.

Read On

Cheesewheels With Extra Cheese at the Dairy Land Drive In of Lander, Wyoming

Cheesewheels: "A cheeseburger patty, battered; then deep fried.  They are served in Lander, Wyoming at the Dairy Land Drive In.  Heres' a picture of the cheesewheels with extra cheese menu offering. 

I stopped there on a road trip this week. Never got a chance to try it. The service was so bad, I ran across the street to the Taco Bell. There I was graced with the presence of the "manager". A young guy with a pony tail half way down his back. Sitting on his ass talking with friends while two other (nice) employees struggled to keep up with the rush of customers.

When I worked as a pizza delivery driver almost 20 years ago the manager was in the back busting his butt making pizzas with the rest of us.

Why are people so lazy today?

The Future Of Hospitalist Medicine?

Are we looking at the future of hospitalist medicine?

The Refugee posts his concerns over at Hospitalist With A View.  It's an excellent read on how the economics of medicine drive the medicine itself.  You get what you pay for.  If you value pay well for  high cost procedural/surgical medicine, you will get systems in place to deliver high cost procedural/surgical  medicine with excellent efficiency.  If you paid cognitive medicine well, you would get systems in place to deliver highly efficient cognitive medicine with excellent efficiency.    Here's a clip below.  Go read the rest.

Bitemporal Wasting In Obama Due To Teleprompter Helmet? You Make The Call.

A reader asks another question:

Look at Obama today. He has bitemporal wasting. I have not noticed it before. Have you? What do you think?

It could be from his teleprompter holder

Patient Dumping And Hospitalist Co-Management.

A reader asks the question:

Has hospitalist co-management simply turned into outright, legitimized patient dumping?

I get called from the ER to admit a perforated viscous in a 80 year old woman with abdominal pain, and copious free air on CT.  General surgery was called, told the ER "admit to the hospitalist" and refused to even call our service to discuss it as he/she "not seen the patient yet" and told the ER when pressed when he/she would be in, it would be "some time tonight" rather than the 1 hour required by our medical staff bylaws.

This is how not to form good working relationships.  I swear, sometimes it seems like subspecialty groups consider hospitalists the enemy.  You try and do the right thing by having physician to physician communication and some doctors find themselves above the process.  Almost as if they are too good to be bothered with such annoyances as patient consults.  I have stopped counting how many times I have had a doctors yell at me for "only consulting me (CPT 99253, 99254, 99255) on the uninsured patients" or "only consulting me on the complicated patients".  I have stopped counting how many times certain doctors yell at me for asking for their help in evaluating patients that I have no formal training.

   

I even cared once for a patient with a surgical problem where in I was forced to go through  four surgeons of varying subspecialties whom were all qualified to evaluate the surgical condition for which I was requesting assistance.  It took me 45 minutes to hunt down a doctor, who finally agreed to see the patient after their surgical and clinical rounds, the following day.  

When you don't have back up to evaluate and manage conditions for which you are not trained to handle, you simply stop accepting them to your primary service until that changes.   I would not put myself into a position as an attending where I would accept a dying patient and no subspecialist to help evaluate conditions for which I am not trained to manage.  It would be like me transferring the patient from Happy's regional referral center to a small town community hospital.   I do not  agree to admit a patient with a primary condition for which I am not able to manage unless I am guaranteed  immediate access to a subspecialist who can help me in co-management. 

I have no problem admitting surgical patients when I know the surgeon is available immediately. When I see the  patient as a consultant or a primary, nothing is different for me.  But making sure the doctors are available without jumping through hoops is key.

Busy Hospitalist Night Shift Experience. I Break Down The Economics.

I had a really busy hospitalist night shift.  13 admissions, one consult and one central line in a 12 hour shift.

7 : 99223 high level complexity admissions

4 : 99220 high level observation admissions

2 : 99291 critical care admissions

1 : 99233 ortho follow up consult

1 : 36556 central line

with 1/2 hour left to write this post.

If every one of those patients were Medicare, how much did I bill for the night? Let's see

7 (99223) About 5 Total RVUs worth about $170 each for a total of 35 RVUs/$1190

4 (99220) About 4 Total RVUs worth about $140 each for a total of 16 RVUs/$560

2 (99291) About 6 Total RVUs worth about $200 each for a total of 12 RVUs/$400

1 (99233) About 2.5 Total RVUs worth about $90

1 (36556) About 3.5 Total RVUs worth about $110

Remember, it's all relative. Tonight, a record night, I produced a total RVU (work RVU+practice expense+malpractice) of about 69 RVUs. If every one of those encounters was a Medicare patient, I would have collected close to $2,400. What is RVU?  You need to understand the process to continue reading.  

If you look at just the work RVU's, that RVU amount that is attributed only to physician expertise, education and effort (strip out the practice expense and malpractice expense from the total RVUs) , the workRVUs amounts to about 52 RVUs for 14 complicated admissions/critical care/consults/ and a central line.

Lets compare this to the Medicare payment to the orthopaedic surgeon for doing the total knee arthroplasty (CPT 27447) that I was consulted on. It is worth about 23 work RVUs. Add in the 4 work RVUs for the consult before surgery and you're looking at 27 work RVUs to do a total knee arthroplasty. Now granted, this surgery carries with it a global 90 day period for which the surgeon is required to care for the patient as part of their agreement.

To produce 52 work RVUs an orthopaedic surgeon would have to perform just under two total knee arthroplasties (about 1.9). So lets assume they do that in the 11 hours. Let's say the consult takes 1/2 an hour ( that's pushing it). Two consults would take an hour. That leaves 10 hours of time for 1.9 surgeries and all post operative follow up.

It would take an orthopaedic surgeon a time commitment of 5 hours over a 90 day period for their total knee to produce the volume equivalent to the time and effort put in by a hospitalist on a record busy day.

Let's even assume that it takes 5 hours of OR/post OR cares to do a total knee (which is perhaps double or triple the actual time committment), if you are a medical student would you rather spend 11 hours admitting 14 people or would you rather spend 11 hours doing surgery on two of them.

The answer is simple. And that's why medical students know exactly what they are doing when they shun cognitive only medicine in favor of the lucrative procedural/surgical based subspecialties. When you can earn the same amount seeing two patients with a five hour commitment that in actuality may take less than 1/2 that much, deciding what medical career to pursue is not rocket science. And it's all courtesy of the RUC.

Before some subspecialists spam me as saying I knew what I was getting into, let me say I love my job. Hospitalist medicine has left the irrational constraints the RVU pot. This discussion is not personally about me, but rather about the reality of the model for which we choose to pay doctors to perform.

America, the RVU scam is directly responsible for the exacerbating debacle in McAllen, Texas, a pattern of deceit that is also present in every corner of this country . You should be very afraid of your health care. The RUC and its RVU scam has turned you into bars of gold.

Bars of gold that the medical students of today have gone searching for, by their shunning of the cognitive based specialty of internal medicine.

Addendum:  I forgot to add, the central line, from start to finish took me 20 minutes.  The observation admissions, which paid slightly more than the central line took at least 45 minutes.  It's not effort that is being paid.  The central lines are easy compared to admissions.  But they pay so much better on a time based axis.  And that has nothing to do with skill and everything to do with the RVU as determined by the RUC.  It takes far more skill for me to think my way through a differential diagnosis than it does for me to swab some cleanser on the skin and stick a needle in a vein.

For more information on hospitalist salary, visit

• Hospitalist compensation salary survey 2010 (SHM/MGMA) based on 2009 data
• Hospitalist subsidy and support payments update for 2011, based on 2010 data.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital:  (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic:  (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view

Audit the Fed Economics

How hypocritical for our government to forcibly seize private assets and demand a gutting of the executives in charge, while practicing unsustainable irresponsible policy at the same time. Hypocrites. All of them.

When is America going to learn that governments that promise everything end up delivering on nothing.

First 10 K Ever Coming Soon, I'm Sure.

Congratulatinos to Mrs Happy for running four miles for the first time in her life.  And she came in at just over a nine minute mile. Next goal?  Perhaps a 10K by fall.  Keep it up.

It wasn't long ago you were saying how you couldn't even go a mile.  The body has an amazing way of adapting to exercise. Every day it gets easier and easier.  Before you know it, you're running marathons.

Perhaps instead of spending 1 trillion dollars (that Obama has promised to print) we don't have on worthless health care we can't afford, we should invest in exercise and reap the benefits that we know exist but are too entitled to put in the effort to work for.     What we need is a redirection of our efforts from insuring everyone into efforts to ensure health in everyone.   I laugh at the assertion that spending 1 trillion dollars now will somehow make health care cheaper for everyone in the future.    The thought is as hilarious as it is ludicrous. 

The benefits of exercise are undeniable.  From dramatically cutting the risk of many cancers, stroke and heart disease to improving productivity and reducing sick days.  It seems like we as a nation feel entitled to health care, but not health.    

Why do we feel entitled to health care but not health?   Do we feel no responsibility to the condition we find ourselves in?  I  understand that many conditions are genetic.  I also understand that many genetic conditions only show clinical relevance based on the lifestyle habits one chooses to follow.  Some folks do everything right and still get the short end of the health stick.  Some people do everything wrong and find themselves dying of old age.  

However, if you look at population statistics, both ends of the spectrum represent such a small minority that they simply don't matter.  If you fail to take care of yourself, you will, in all likelihood suffer the consequences.  

I'm here to tell you that we won't be able take care of you when those consequences come home to roost.  When the 1 trillion dollars turns into 2 trillion dollars turns into 3 trillion dollars.  When we find out that no matter how much money we spend, health care does not create health.  When we realize that we already spend twice as much as every other country for health care and spending more isn't' going to make us any healthier.  When we finally bankrupt this country after realizing we just did the mother of all oops.  

Only then will the people who get it.  Those that are taking care of themselves now.  Those sacrificing at the gym.  Watching what they eat.  Spending time moving instead of watching TV.  Those are the folks who will reap benefits of their sacrifice, when those all around them are being sent home on hospice in a government health care system that kept promising health, but in the end could only promise health care.  Until the day it couldn't even promise that.